Uncommon cause of acute abdomen: volvulus of gallbladder with

CASI CLINICI, STUDI, TECNICHE NUOVE
Case reports, Studies, New Techniques
Uncommon cause of acute abdomen:
volvulus of gallbladder with necrosis.
Ann. Ital. Chir., 2011 82: 137-140
Case report and review of literature
Chiara Bagnato, PieroVincenzo Lippolis, Giuseppe Zocco, Christian Galatioto,
Massimo Seccia
U.O. Universitaria Chirurgia Generale e d’Urgenza AOUP, Pisa, Italy
Uncommon cause of acute abdomen: volvulus of gallbladder with necrosis. Case report and review of literature
Gallbladder volvulus is a rare condition which can mimic an acute cholecystitis. This condition is characterized from a
rotation of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery. Preoperative diagnosis is
difficult.
This is an acute surgical emergency that must be treated with immediate detorsion and cholecystectomy.
We report a case of acute gallbladder torsion in an elderly man and review the clinical aspects of the disease in the
context of the available literature.
KEY
WORDS:
Acute adbomen, Gallbladder, Torsion, Surgery, Vulvulus.
Introduction
Case report
Volvulus of gallbladder is an uncommon cause of acute
abdomen that is usually found at the time of exploration
for an acute abdomen. It results from congenital or
acquired anatomical abnormality of gallbladder in which
the organ twists partially or thoroughly on its long axis
with impairment of vascular supply 1,2. Preoperative diagnosis is always difficult 3.
Gallbladder volvulus may occur in any age group, however the incidence is higher in elderly woman and
appears most often with acute symptoms that may mimic an acute cholecystitis.
We report a case of acute gallbladder torsion in an elderly man and review the clinical aspects of the disease in
the context of the available literature.
An 85 Years old man was transferred from a peripheral
hospital to our Emergency Department with a two day
history of colicky abdominal pain at the right upper
quadrant, with localized peritonism and vomiting. He
described a similar episode of this pain during the preceding month treated with non- steroidal anti-inflammatory (NSAIDs) and antibiotics. The past medical history was for aneurysmectomy for AAA, aortocoronaric
by-pass, myocardial infarction, atrial fibrillation, COPD,
hypertension and a recent intervention for small-bowel
adhesive obstruction and a median incisional hernia that
was repaired with the insertion of a Dual-mesh.
On physical examination there were following vital signs:
HR 110 b/min; BP 120/60; T 37,6; oxygen saturation
92% on air. The WBC was 16.620, LDH 260 U/L,
Glucose 110; liver function tests were normal. Physical
examination reveals gauntness, a palpable mass and tenderness in the right upper quadrant area with localized
peritonism. Murphy sign was positive. Chest X Ray was
unremarkable; abdominal X Ray showed right sided
colonic faecal loading and excluded a perforation of
hollow viscus. Abdominal US examination showed a
distended gallbladder with thickened wall and fluid col-
Pervenuto in Redazione Dicembre 2010. Accettato per la pubblicazione Febbraio 2011.
Correspondence to: Bagnato Chiara, U.O. Universitaria Chirurgia
Generale e d’Urgenza AOUP, Via Roma 67 Pisa (e-mail: [email protected]).
Ann. Ital. Chir., 82, 2, 2011
137
C. Bagnato, et al.
Fig. 1: Gallbladder Volvulus.
lection around the gallbladder. No stones were detected at US.
The patient underwent an urgent laparotomy, with preoperative diagnosis of acalculous cholecystitis with possible gangrene and perforation. We found the Kocher
(right subcostal) incision because the patient had a median dual mesh for a previous incisional hernia. At laparotomy the gallbladder was distended and necrotic. It was
completely rotated clockwise around its mesentery and
there were no gallstones in gallbladder. Cholecystectomy
was performed.
Histopatology was: “gallbladder completely disepitelized
with hemorrhagic necrosis of the wall (A1-A2).
The patient was discharged on the fifth post-operative
day.
Discussion
Gallbladder volvulus was recognized for the first time in
1898 when Wendell described a case in a 25 years old
pregnant patient4. Since than more than 300 cases have
been described in literature. True incidence is unknown:
85% of cases occur between the age of 60 and 80 years,
with a female to male ratio of 3:1 in adults and of 1:4
in paediatric age group 5-7.
The aetiology of gallbladder volvulus is unknown but
many factors are important in pathogenesis. Exist two
anatomic variants of the gallbladder anatomy that might
undergo torsion: in one type there is a long mesentery
that is prone to torsion; in the other type the mesentery supports only the cystic duct allowing motility of
the gallbladder along its vertical axis. This condition may
be congenital or acquired. There are many factors that
contribute to non fixation of gallbladder to the inferior
margin of the liver like the loss of fat and the atrophy
of the tissues that may occur with advancing age that
leaving the gallbladder hanging freely. Other precipitat-
138
Ann. Ital. Chir., 82, 2, 2011
ing factors for the torsion include increased or intense
peristalsis of the neighboring organs (stomach, duodenum, colon) kyphoscoliosis of the spine, visceroptosis,
atherosclerosis of the cystic artery 5,8,9,10.
The role of gallstones is debatable and approximately 2033% of the patients with gallbladder volvulus have gallstones 11. Torsion of the gallbladder can be complete
(>180°) with compromission of the blood supply to the
organ, or incomplete (< 180°) that causes intermittent
symptoms of biliary colic. The direction of the torsion
may be clockwise or anticlockwise. Intense peristalsis of
stomach or duodenum has been implicated in clockwise
rotation, while peristalsis of transverse colon is implicated in anticlockwise rotation 12.
Preoperative diagnosis of gallbladder torsion is difficult
because this condition can mimic an acute cholecystitis.
Lau et al 13 proposed a triple triads for a clinical diagnosis of a gallbladder torsion which includes patient’s physical characteristic (elderly, thin, and deformed spine),
symptoms (right upper quadrant abdominal pain, early
onset of vomiting and a short history of symptoms) and
physical signs (abdominal mass, a lack of toxaemia or
jaundice and a discrepancy in the pulse and temperature).
Although patients typically present with acute onset of
abdominal pain and have right upper quadrant tenderness. A palpable mass may be present in only 20 to 50%
of patients and gallstones are found in only 20-33% of
cases 14. Differential diagnosis is with acute cholecystitis, but low frequency of fever and jaundice, absence of
toxaemia and poor response to antibiotic therapy can
help to differentiate 15. Volvulus interferes with blood
supply and bile flow. Therefore gallbladder wall thickening, hydrops and finally gangrene develop.
Instrumental studies may contribute to the diagnosis but
are often non specific. An elevated white blood cells
(WBC) count is a frequent finding; liver function tests
are commonly normal16 . US and CT studies often reveal
a large floating gallbladder without gallstones and a
thickened wall. Specific signs are the presence of the gallbladder outside its normal anatomic fossa, inferior to the
liver or in a transverse orientation, a conical appearance
of the neck with discontinuity of the lumen 17-19 . Wang
20 described a “bulls eye” image of gallbladder volvulus
from the accumulation of radioactivity in the gallbladder on the hepatobiliary nuclear scan20. MR Imaging
findings include a high signal intensity within the gallbladder wall on T1 weighted images suggesting hemorrhagic infarction and necrosis 21.
The presence of a large floating gallbladder away from
normal anatomical location with gross wall thickening
and without gallstones in an elderly woman with kyphosis, can be suggestive of gallbladder volvulus.
Early diagnosis prevents perforation of a gangrenosus
gallbladder and should result in a surgical mortality of
less than 5% 14. Although detorsion and pexis have been
described, the surgical treatment is cholecystectomy22.
Evacuation of gallbladder may be necessary to allow
Uncommon cause of acute abdomen: volvulus of gallbladder with necrosis. Case report and review of literature
grasping with instruments. Detorsion of the gallbladder
must be precocious to prevent injury to the bile duct.
Laparoscopic cholecystectomy is now recommended at
the first choice: it has the benefit of confirming diagnosis and early postoperative recovery 23. Furthermore
the presence of a long mesentery and the separation of
the gallbladder from its liver bed, usually makes laparoscopic approach much easier than in the case with the
ordinary cholecystectomy. Our patient had an open
surgery because his clinical condition were seriously compromised and a laparoscopic approach was dissuaded.
Prognosis for the gallbladder volvulus is in function of
the general condition and the rapidity of operation. It
is currently generally good 24.
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Conclusions
Gallbladder Volvulus is a rare cause of acute abdomen
that mimics cholecystitis with fails to improve by conservative treatment. The torsion can alter the blood supply to the gallbladder, induces necrosis and can complicate with perforation and peritonitis. The surgeon should
have high index of suspicion for volvulus of gallbladder
in elderly patient with signs of acalculous acute cholecystitis and proceed with prompt surgical treatment.
Cholecystectomy in emergency is recommended and prevents complications.
Riassunto
Il Volvolo della Colecisti e una condizione piuttosto rara
che può simulare, nella sua manifestazione clinica, una
colecistite acuta. Tale patologia è caratterizzata da una
rotazione della colecisti attorno al proprio asse rappresentato dal dotto cistico e dall’arteria cistica. La diagnosi preoperatoria è piuttosto difficoltosa. Si tratta comunque di una patologia che richiede un trattamento chirurgico d’urgenza, mediante derotazione e colecistectomia, dal momento che comporta la sofferenza vascolare
del viscere ed il rischio di una peritonite.
Abbiamo riportato il caso di un uomo di 85 anni, giunto alla nostra osservazione in urgenza da un ospedale di
periferia, con diagnosi di addome acuto destro, che è
stato sottoposto ad intervento chirurgico urgenza nel
sospetto, agli accertamenti preoperatori ed in base alla
clinica, di una colecistite acuta alitiasica. Il paziente presentava in realtà un volvolo della colecisti, ed è stato
sottoposto ad intervento di colecistectomia.
La colecistectomia rappresenta il trattamento di scelta in
caso di un volvolo della colecisti.
Esistono alcuni segni clinici ed agli esami strumentali
che possono indirizzare il chirurgo ad effettuare una corretta diagnosi preoperatoria, ma non sempre ciò è possibile come anche dimostrato da una revisione della letteratura disponibile.
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